Next week, the Sunset Advisory Commission will meet to hear testimony regarding its scathing report on the Department of State Health Services (DSHS), one of the largest and most important state agencies. “Scathing” is a term that gets thrown around a lot but really ought to be reserved for dispatches like this one, released in May, which saves special condemnation for the department’s many failures in running the state’s public mental health system. “This experiment was well-intentioned,” the report says, referring to the department as a whole, but DSHS “has struggled to address longstanding concerns, despite clear and repeated direction.” Because of this, most of the Sunset staff recommendations don’t break new ground but “reflect a need for the agency to simply do its job better.”
While the report specifies nine areas for improvement, its authors note that this list is constrained by the resources of their review, not by any limit to the department’s problems. They even suggest that by the time the Sunset review concludes next fall, future reports may question “continuation of DSHS as a standalone agency.” The report goes beyond critical and gets existential.
Some of the recommendations are specific, like calls to combat fraud in the EMS industry, to better protect vital statistics information, and to reduce the department’s regulatory role. But some are just damning pronouncements: “DSHS Has Not Provided the Leadership Needed to Best Manage the State’s Public Health System;” and “DSHS’ Numerous Advisory Committees Lack Strategic Purpose, Limiting Their Effectiveness and Wasting Resources.”
Perhaps the broadest and most troubling part of the report is its wholesale indictment of the state public mental health system. That system has two parts: outpatient community-based treatment, and inpatient treatment through the state mental health hospitals. According to the report, both are broken.
The mental health hospital system, finds the Sunset Commission, is in a crisis that “Requires Action, Starting Now” because of understaffing, inadequate capacity, and aging, remote facilities that need more that $200 million in upgrades. These aren’t new problems, the report notes: “Numerous plans and studies attempting to correct pervasive state hospital system issues have yielded few results, and the success of future plans is questionable… The State essentially operates the same mental health hospital system as during the last Sunset Advisory Commission review 15 years ago, despite years of planning and discussion.”
At least one thing has changed in that period, but it hasn’t helped matters. In recent years, Texas judges have sent more and more psychiatric patients to the hospitals for “competency restoration”—that is, to receive psychiatric treatment until they’re mentally competent to stand trial—exacerbating bed shortages. The special challenge of these so-called “forensic commitments” is that if state hospitals are full, a person charged with a crime who needs inpatient treatment can be held in jail, untried and often untreated, until space opens up. Long waits have led to lawsuits. Under pressure from the courts, the Department of State Health Services has reduced the wait time for forensic patients from an average of 77 days to 17 days over the last few years, but at a price. More forensic beds means fewer civilian beds, and this year, forensic commitments exceeded civil ones for the first time. In other words, if you need treatment from a state mental health hospital, your odds of getting it are now better if you’ve committed a crime than if you haven’t.
The outpatient mental health system is hardly better. The department “has not seized obvious opportunities to integrate… mental health and substance abuse services,” the report found. Half a million Texans suffer from a severe mental illness, two million have a substance abuse problem, and there’s plenty of overlap between those populations. But screening, assessment and treatment systems for the two groups remain separate, which “allows people with complex, co-occurring mental health and substance abuse issues to more easily fall through the cracks.” The department’s funding structure for community mental health providers is “irrational,” “byzantine,” and “disconnected from performance,” and despite collecting hundreds of data points, the department knows little about what programs work and why. These systems need “a complete re-evaluation and overhaul.”
In short, the Department of State Health Services fails to plan strategically or address structural problems because it’s “constantly operating in crisis management mode,” says the Sunset staff report. Mercifully, the report’s authors blame this on the department’s overly ambitious mission rather than the department itself. “[F]ew, if any, state agencies have the breadth and scope of DSHS’ responsibilities,” they write. “…[I]n many ways DSHS was set up to be a ‘jack of all trades, and a master of none.’” But this may be cold comfort if a future report recommends, as this one suggests, that state legislators dismantle the Department of State Health Services altogether.